The nurse is reviewing laboratory results and nurse’s notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)
Observe for signs of respiratory distress and monitor oxygenation by pulse oximetry.
Keep infant in warmer with bilirubin lights to maintain temperature of 97.6° F (36.4° C).
Monitor temperature.
Continue to monitor glucose levels.
Explain to the mother that the baby’s respiratory rate needs to be below 60 breaths/minute to be able to breastfeed.
Tell the mother that she will need to discuss any concerns with the neonatologist.
Inform the mother that the baby is stable enough to take out of the warmer and bilirubin lights.
Correct Answer : A,B,C,D
Choice A rationale
Monitoring for respiratory distress and checking oxygenation by pulse oximetry are critical in newborns, as they can indicate hypoxemia or respiratory issues requiring prompt intervention.
Choice B rationale
Maintaining the infant's temperature at 97.6°F (36.4°C) using a warmer and bilirubin lights is essential for thermoregulation and treating jaundice, ensuring proper physiological stability.
Choice C rationale
Regular temperature monitoring is vital to detect any signs of hypothermia or hyperthermia, which can indicate underlying health issues and guide appropriate interventions for the newborn.
Choice D rationale
Continued monitoring of glucose levels is crucial for detecting hypoglycemia, a common condition in newborns that can lead to seizures, brain damage, or other severe complications if left untreated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Asking another nurse to validate the costal angle finding is unnecessary, as the increased costal angle is a common physiological change during pregnancy due to the expanding uterus.
Choice B rationale
Examining for tissue anoxia, such as pallor, is not relevant in this scenario, as the nasal stuffiness and nosebleeds are likely due to increased blood volume and hormonal changes in pregnancy.
Choice C rationale
Requesting the healthcare provider to evaluate the client's respiratory status is unwarranted, as the described symptoms are typical physiological adaptations during pregnancy and not indicative of respiratory pathology.
Choice D rationale
Documenting the respiratory finding as normal is appropriate, as the increased chest circumference, thoracic breathing, elevated diaphragm, and increased costal angle are expected physiological changes during pregnancy.
Correct Answer is A
Explanation
Choice A rationale
Bradycardia (heart rate 56 beats/minute) is common postpartum due to increased stroke volume and reduced heart rate, reflecting physiological adaptation after delivery.
Choice B rationale
Saturating two perineal pads per hour is excessive and could indicate postpartum hemorrhage, requiring immediate evaluation and intervention.
Choice C rationale
A soft, spongy fundus indicates uterine atony, a serious condition requiring urgent intervention to prevent postpartum hemorrhage.
Choice D rationale
Unilateral lower leg pain could indicate deep vein thrombosis (DVT), a significant postpartum complication needing immediate medical attention.
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